January 5, 2023
The following payment policies received their annual review with no changes:
- After Hours Services
- Facility Fees: Clinic Services, Professional Fees, and Specialty Services-Treatment Room
- Home Birth Kit Supplies
- Modifier 79 – Unrelated Procedure/Service by Same Provider during Postoperative Period
The following payment policies received their annual review with the changes:
-
Blood Draw/Venipuncture
Added cross reference to policy “contract exclusions/disallowed charges – inpatient and outpatient facility services” where limit is also one unit/per provider/per day on facility claims. -
Claims Editing Exceptions
Added an exception to the policy for self-funded groups that may opt-out of claims editing. -
Modifier 80, 81, 82 – Assistant Surgeons (Physician)
In the policy section, clarified that the operative report must document the specific services that the physician assistant rendered rather than just mention a physician assistant was present. Added paragraph to indicate services with indicator flag “0” in the National Physician Fee Schedule must be accompanied by documentation for the need of a surgical assistant. -
Modifier AS – Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Services for Assistant at Surgery (Non-Physician)
In the policy section, clarified that the operative report must document the specific services that the non-physician assistant rendered rather than just mention a physician assistant was present. Added paragraph to indicate services with indicator flag “0” in the National Physician Fee Schedule must be accompanied by documentation for the need of a surgical assistant. Added a paragraph to indicate that the non-physician assistant must add their own identification number upon claims submitted. -
Modifier SL – State Supplied Vaccine
In the policy section, added the final paragraph noting that modifier SL is not appropriate to be appended to vaccine administration codes. Added a new section codes/coding guidelines and listed the applicable vaccine administration codes subject to the policy. -
New and Established Patient Guidelines
In the policy section, clarified the descriptions for “new” and “established” patients as set forth in the AMA CPT Codebook. -
Prolonged Services for Labor Management
In the codes/coding guidelines section, updated the codes to reflect revisions to code descriptions, new and terminated codes effective January 1, 2023.